Though anorexia nervosa was rare until the second half of the 20th century, it certainly existed beforehand. The first descriptions of anorexia nervosa in the Western world date from the 12th and 13th centuries, most famously Saint Catherine of Siena (1), who denied herself food as part of a spiritual denial of self. By the sixteenth century, ascetics were considered witches and burned at the stake. There are several other clinical descriptions of "wasting disease" in the 17th-19th century, and in the early 20th century, anorexia was considered an endocrine disorder and treated with pituitary hormones.
In 1973, Hilde Bruch published a book with a number of case studies, called Eating Disorders: Obesity, Anorexia Nervosa, And The Person Within￼. As the disorder reached public awareness in the 1970s, cases increased, spreading beyond the upper class.
Bulimia (binging and then purging via exercise, vomiting, or laxatives) is first reliably described among some of the wealthy in the Middle Ages, who would vomit during meals so they could consume more (2). Apparently this behavior did not happen in ancient Rome despite a common conception otherwise (3). The first clinical paper on bulimia was published in 1979—Bulimia nervosa, an ominous variant of anorexia nervosa.
The cases cases of anorexia and bulimia escalated in the 1970s and 1980s, and though some will say they peaked in that time, the national survey data suggests that bulimia, especially, continues to escalate. While most scholars will point to cultural pressures for thinness, increasing depression and obsessive compulsive behavior, and increased dieting behaviors as precipitants for eating disorders, it is impossible to ignore the fact that the 1970s and 80s is when the rates of obesity in the United States began to increase at an unprecedented rate, and low fat eating began its popular progression through the mainstream.
There is a third eating disorder, binge eating disorder, where periodic food binges are not compensated by restricting or purging behavior. While many obese people eat normally, binge eaters will consume up to tens of thousands of calories in a singe day, entire bags of candy, or dinner from five or six fast food restaurants, one after the other. Again this disorder has been described for centuries, but seems to have escalated only recently (4). Binge eaters make up about 1/3 of the people who seek medical treatment for obesity.
All eating disorders remain relatively rare. Anorexia afflicts about 0.5% of women and 0.1% of men. Bulimia around 1-3% of women (also 0.1% of men), and binge eating disorder 3.3% of women and 0.8% of men. Anorexia nervosa remains the most deadly of all psychiatric disorders (5), with a 5-10% death rate within 10 years of developing the symptoms, and an 18-20% death rate within 20 years. Anorexia is endemic in the fashion industry, to the point where models are now being airbrushed to add curves (6).
Eating disorders in adolescents are strongly predicted by the earlier presence of depression, bipolar disorder, and anxiety. The eating disorders also appear to be genetic (7)(8), perhaps related to inherited differences in serotonin receptors.
With the growing prevalence, genetic susceptibility, and correlation with increases in obesity and consumption of industrialized food (not to mention the zinc connection), one can't help but wonder if the eating disorders are yet one more disease of Western civilization, most strongly predicated by our poor diets. Much of the natural progression of anorexia can be explained by disordered thinking about body image combined with the process of starvation itself. Given the speculation that our modern, processed, sugary and grain-rich diet leads to inflammation, leptin and insulin resistance, and obesity, disordered thinking and restrictive or purging behaviors may be the only ways to remain "skinny" on a standard diet. The cost is high, and borne primarily by our young women.
A personalized approach, based on treating underlying depression, anxiety, nutritional deficiencies, and teaching that our bodies deserve to be nourished with proper, whole foods can be surprisingly effective. Do eating disorders exist in a population where there is no obesity? I don't know. I imagine they are vanishingly rare.
Copyright Emily Deans, MD